New UK research appears to back an official recommendation for the inclusion of new indicators in the QOF covering dietary advice for diabetic patients.
The Department of Health study – one of the largest trials on the impact of diet and exercise on HbA1c control – found that in patients with type 2 diabetes, just 6.5 hours of specialist dietary advice can lead to improvement in blood sugar control compared with patients who receive usual care.
But researchers found that increased activity conferred no additional benefit when combined with the diet intervention.
It comes after the independent QOF indicator advisory committee meeting last month, when it was agreed that indicators promoting dietary review and structured patient education for patients with type 1 and type 2 diabetes should be added to the NICE menu of indicators and recommended for negotiation and possible inclusion in the 2012/13 QOF.
The research, presented at the American Diabetes Association conference in San Diego this week, assessed 593 adults aged 30 to 80 years diagnosed with type 2 diabetes between five and eight months earlier.
Of these, 99 were assigned to usual care, 248 to diet advice only, and 246 to diet advice plus exercise. Usual-care patients received an initial dietary consultation plus follow-up every six months. Diet-only group patients were given a dietary consultation every three months with additional nurse support each month. Diet and exercise patients received the same as diet-only patients but were also asked to do 30 minutes of brisk walking five times a week, measured with pedometers to assess compliance.
In the usual-care group, blood sugar control had worsened, with mean HbA1c increasing from 6.72% to 6.86% over six months, before falling back to 6.81% at 12 months.
In the diet-advice group, HbA1c fell from a mean 6.64% pre-intervention to 6.57% at six months and 6.55% at 12 months.
Differences were also seen in body weight and insulin resistance between the intervention and control groups, but blood pressure was similar in all groups.
An intention-to-treat comparison showed no differences between the intensive diet intervention and the intensive diet intervention plus activity for any primary outcome, apart from in those patients with the highest HbA1c, insulin resistance, or body-mass index at baseline.
Study leader Dr Robert Andews, consultant senior lecturer at the University of Bristol, concluded: ‘Most health services employ healthcare workers who can promote dietary improvement in a way similar to that used in this study, whereas fewer are trained to promote behaviour change for physical activity.’
‘These findings suggest that intervention at this early stage should focus on improving diet, since the additional cost of training healthcare workers to promote activity might not be justified.’
The researchers suggested the apparent lack of effect of increased activity could be due to insufficient intensity, or that it was too early in the disease process for exercise to show an effect.
‘Our findings support the redesign of diabetes services to increase dietary management at an early stage. Because the intensive diet intervention was designed to be delivered by practice nurses with dietician support, this approach could be translated into community-based services.’